2022 FPC High School Boundary Waters Retreat

July 24th-30th
$200 Total Registration Cost
- $100 Deposit by April 3rd
- $100 Due by July 10th
Registration Deadline February 16th

For your information.

FPC High School Summer Boundary Waters Retreat 2022

Step 1 of 3

Mission Trip Participant Information
Participant's Full Name*
First Last
Participant's Email*
Participant's Phone Number*
Participant's Gender*
Participant's Date of Birth*
Month
Day
Year
Participant's T-Shirt Size*
(Adult Sizes)
Participant's Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian/Emergency Contact Information
Parent/Guardian/Emergency Contact's Name*
First Last
Relation to Participant*
Parent/Guardian/Emergency Contact's Email*
Parent/Guardian/Emergency Contact's Phone*
Does the participant have another Parent/Guardian/Emergency Contact?*
- Yes
- No
Other Parent/Guardian/Emergency Contact's Name
First Last
Relation to Participant
Other Parent/Guardian/Emergency Contact's Email
Other Parent/Guardian/Emergency Contact's Phone

Critical Medical / Health Information
Does the mission trip participant have any allergies, food allergies, prescription medications, mental or physical health issues that may impact their experience on the trip?*
- Yes
- No
Due to HIPAA compliance laws, we will not collect sensitive medical information on the internet registration form. You may download the required medical information registration sheet or it will automatically be emailed to you upon successful completion of this registration form.
Primary Care Physician Information
Primary Care Physician's Name*
Primary Care Physician is Located in*

(City & State)
Health Insurance Insurer*
Health Insurance Policy Number*

Emergency Medical Authorization & Waivers
Should it be necessary for me or my child to have emergency medical treatment while participating in this trip, I hereby authorize First Presbyterian Church of Spirit Lake, IA personnel to use their judgment in obtaining emergency medical services. I further authorize any individual selected by these churches' personnel to render such emergency medical treatment as he/she may deem necessary and appropriate including but not limited to medical assistance, assessment, and surgery or life saving measures if needed. I understand that the First Presbyterian Church of Spirit Lake, IA has no church insurance which pays the medical or hospital costs that might be incurred on behalf of me or my child. Consequently, I understand that any and all such costs will be my sole responsibility.
By signing below I understand that photos, video interviews, and electronic images of me or my student might be used for the church's promotion, education and future publication.
By signing below I acknowledge that I release the First Presbyterian Church of Spirit Lake, IA from liability and legal action stemming from my own actions, or my child’s behavior, injury and/or activity during the event.
Community Guidelines and Covenant*
I certify that I have read the Community Guidelines and Covenant, understand them and indicate that I will live, in community, with fellow trip participants, leaders, and staff by following the guidelines as they are presented. I understand that if I break the covenant or am unable to follow the guidelines I can be sent home, at my own expense.
- Yes
I acknowledge that I have read, understand and have signed this form in preparation to attend and participate in the FPC High School Summer Boundary Waters Trip. By signing I also give my permission for myself and my child/minor charge to be given medical treatment, medical assistance, assessment and surgery or life saving measures if needed:
Digital Signature of Parent/Guardian/Adult Participant*
First Last
Comments
This field is for validation purposes and should be left unchanged.

FPC High School Summer Boundary Waters Retreat 2022

Step 1 of 3

Mission Trip Participant Information

Parent/Guardian/Emergency Contact Information

Critical Medical / Health Information

Primary Care Physician Information

Emergency Medical Authorization & Waivers